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1901 FM 423, Suite 100, Frisco, Texas 75033 (972) 377-4777 Fax (972) 377-4780

PATIENT REGISTRATION AND MEDICAL HISTORY

Patient: _________________________________________________ Preferred Name: ______________________ Last First Middle Initial

Home Address: _____________________________________________________City_________________________

State/Zip:_________________________Email:______________________________________ ______

Sex: □M □F Date of Birth: _______________ Age: __________ SS#: ____________________________________

Check one: □Single □Married □Divorced □Widowed Employer: ________________________________________

Home Phone #: _______________________ Work #: __________________ Cell #: __________________________

Responsible Party (Parent/Guardian of Minor) Information

Name:______________________________________________ Date of Birth: ________________________________

How did you hear about us? (Please check all that apply) Location/Drive-By Postcard/Mailer Insurance Company Facebook/Social Media

Google Other Internet Source (Please specify):________________________________ Referred by Patient/Staff/Doctor (Please list): ________________________________________________

EMERGENCY INFORMATION: Name: __________________________ ____ Relationship: ____________________

(Someone NOT living with you) Address: ________________________ _____ Phone #: _______________________

Dental Insurance Information (YOU DO NOT NEED TO FILL OUT IF CARD PRESENT):

Subscriber Name: __________________________________ __________ SS#/ID#: ______________________________

Date of Birth: ____________________ Employer: ________________________________________________________

Insurance Company Name: ____________________________________Group #: _______________________________

This information is strictly confidential and WILL NOT be released to anyone without your consent. It is important, for your safety that the Doctor knows about your Medical and

Dental history. Please make sure this form is accurately completed to the best of your knowledge.

Patient Signature: (or parent if minor) ___________ __________ __Date: ____________________

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General Medical History:

Do you currently have health problems? Yes/No If yes, please explain_____________________________________

________________________ _____________________________________________________________________

Are you under the care of a Physician? Yes/No if yes, please explain _____________________________________

________________________ _______________________________________Date of last exam: _______________

Have you been hospitalized within the last 5 years? Yes/No If yes, please explain ___________________________

_____________________________________________________________________________________________

Physician’s Name: __________________________________ _______Phone #: _____________________________

Women Only:

Are you pregnant? ……………………………………………………………………………………………………………………………………….. Yes/No

If yes, what is the estimated due date?_______________________________________________________

Are you nursing? ………………………………………………………………………………………………………………………………………….. Yes/No

Do you take oral contraceptives? …………………………………………………………………………………………………………………. Yes/No

Please list all medications that you are taking, including non-prescription drugs:

Have you ever had an allergic or adverse reaction to any of the following? If so, please circle:

Local Anesthetics Penicillin Ibuprofen Jewelry/Metals

Topical Anesthetics Erythromycin Codeine Aspirin

Nitrous Oxide Sulfa Drugs Latex Lidocaine/Marcaine

Iodine Other: __________________________________________________________

Patient Signature: (or parent if minor) _________________________________ Date: _____________

Doctor Signature: _________________________________________________ Date: ____________________________

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Do you currently or have you ever had any of the following conditions? Please circle as it applies:

Heart Trouble Hepatitis A (infection) Asthma

Heart Attack Hepatitis B (serum) Emphysema

Open-Heart Surgery Hepatitis C Autoimmune Disease

Tuberculosis (TB) Liver Disease Multiple Sclerosis

Heart Pacemaker Kidney Disease Shortness of Breath

Artificial Heart Valve Bleeding Disorder Sinus Trouble

Mitral Valve Prolapse Anemia Head/Neck Injury

Congenital Heart Defect HIV Gout

Heart Disease Jaundice Mental Disorders

Heart Murmur Respiratory Problems Stomach Problems

Rheumatic Fever AIDS Arthritis

Rheumatic Heart Failure Drug Addiction Seasonal Allergies

Angina (chest pain) Alcoholism Steroid Therapy

Congestive Heart Failure Diabetes Glaucoma

Swollen Ankles Ulcers Tumors/Growths

High Blood Pressure Fainting Spells Cancers

Low Blood Pressure Epilepsy/Seizures Chemo/Radiation

Artificial Joint/Implant Stroke Organ Transplant

Thyroid Problem Sexually Transmitted Disease Marked Weight Change

Nervous Disorders

Other Medical Problems: _______________________________________________________________________________

____________________________________________________________________

Patient Dental History

Yes/No Do your gums bleed while brushing or flossing? Yes/no Do you have frequent headaches?

Yes/No Are your teeth sensitive to hot/cold liquids/foods? Yes/No Do you clench or grind your teeth?

Yes/No Are your teeth sensitive to sweet or sour liquids/foods? Yes/No Do you bite your lips or cheeks frequently?

Yes/No Do you feel pain in any of your teeth? Yes/No Have you ever had any previous difficulty with extractions?

Yes/No Do you have any sores or lumps in or near your mouth? Yes/No Have you ever had prolonged bleeding following extractions?

Yes/No Have you ever had any head, neck, or jaw injuries? Yes/No Have you ever had any orthodontic treatment?

Yes/No Clicking in the jaw? Yes/No Do you wear complete/partial dentures? Yes date made: _________

Yes/No Do you have any other condition, disease, or problem Yes/No Have you ever received oral hygiene instructions regarding your

not contained herein that should be brought to the dentist's teeth and gums?

attention? Please explain: __________________________ Yes/No Do you like your smile? If no explain: ________________________

________________________________________________ _______________________________________________________

________________________________________________

Patient Signature: (or parent if minor) _________________________________ Date: __ _________

Doctor Signature: ______________________________________________Date: _______________________

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At Precision Smiles we want to take optimum care of our patients. We might require more information than other dental offices, but it is to assist you in having a full and healthy life. If you have any of the following conditions, Precision Smiles requires documentation from your physician stating if you need prophylactic antibiotics prior to any dental treatment.

- Heart Murmur - Stent - Mitral Valve Prolapse - Cardiac Pacemaker - Joint Replacement - Shunt - Screws, pins or plates placed in bones - Organ Transplant - Heart valve replacement (mechanical or porcine)

If you are taking the following medications, Precision Smiles requires documentation from your physician stating if you need to stop your medications prior to any dental treatment.

- Warfarin - Actonel - Coumadin - Fosamax - Plavix - Boniva - Clopidogrel - Zometa - Skelid - Aredia - Didronel

You may either bring the medical release from your physician at your appointment or have physician’s office fax the medical release to 972-377-4780. Please make sure the medical release has your full name and date of birth referenced. I understand that if I have any of the above conditions or take any of the above medications: I am responsible for providing Precision Smiles with the appropriate documentations from my physician before my appointment or my appointment will be rescheduled. I understand that withholding information about my health condition could be harmful to me. ___________________________________________ _________________________

Patient’s Signature Date

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At Precision Smiles, we believe that you deserve the best care. That’s why we always present you with the best dental solution

possible to treat your personal situation. Each year, we provide outstanding dental care to hundreds of patients. Some have dental

benefits, but some don’t. If you have dental benefits, congratulations! You are very fortunate. Here are some important things you

should know:

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_______ ■ Your dental benefits are based upon a contract made between your employer and the insurance company. If you have

any questions regarding your dental benefits, please contact your employer or insurance company directly. Dental benefit plans will

never pay for completion of your dental care. It is only meant to assist you.

_______ ■ We currently accept all private care insurance plans. This means that we work with literally hundreds of companies.

Although we can maintain computerized histories of payment by a given company, they do change; therefore it is impossible to give

you a guaranteed quote at the time of service. We estimate your portion based on the most up-to-date information we have, but it is

ONLY AN ESTIMATE. If you would like to know your insurance benefit, we will be happy to file a “pre-treatment authorization” with

your insurance company, prior to treatment. Keep in mind, this is not a guarantee of coverage. This does delay treatment, but it will

give you a more exact out of pocket figure, should you desire.

_______ ■ We will bill your insurance as a courtesy. If insurance does not pay within 90 days, Precision Smiles reserves the right to

request payment in full for services from you and let you collect the insurance funds that are due to you. This is rare, but it is

important that you recognize that the insurance you have is a legal contract between YOU and YOUR INSURANCE COMPANY. Our

office is not, and cannot be a part of that legal contract. Ultimately, you are responsible for all charges incurred in our office.

_______ ■ Precision Smiles does require payment in full for your portion at the time of service. We accept MasterCard, Visa, American

Express, Discover, cash, and checks (a $35.00 fee will be charged for all returned checks). If you are in need of an extended finance

option, we also work with CareCredit, who offers 6 month “same as cash” or longer terms with an interest bearing revolving charge

(with approved credit.)

_______ ■ A specific amount of time is reserved especially for you and we strongly encourage all patients to keep their appointments.

If you must change your appointment, we require at least 24 hour notice to avoid a $35 cancellation fee (emergencies are an

exception).

I agree with the above conditions.

Print Name: ______________________________________________ Date: ____________________________

Patient/Parent Signature: _____________________________________________________________________

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Patient Consent Form

I understand that, under the Health Insurance Portability & Accountability Act OF 1996 (HIPAA), I have certain rights to privacy

regarding my protected health information. I understand that this information can and will be used, but is not mandatory for me to

sign in order to:

o Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that

treatment directly and indirectly.

o Obtain payment from third-party payers.

o Discuss financial and accounting information to all patients on your financial account

o Conduct normal healthcare operations such as quality assessments and physician certifications.

I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of

my health information have informed me. I have been given a copy of your Notice of Privacy Practices prior to signing this consent. I

understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this

organization to obtain a current copy of the Notice of Privacy Practices

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment,

payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you agree then

you are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, however, such revocation will not be retroactive.

May we phone, email, or send you a text message to confirm your appointments? YES NO

May we leave a message on your answering machine at home/cell phone? HOME CELL NO

May we discuss your dental health/account information with a family member? YES NO

If yes, please name persons allowed to discuss: __________________________________________________

_________________________________________________________________________________________

Patient Name: _______________________________________Signature:_________________________________

Relationship to patient: ________________________________Date: ____________________________________

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